Routine Cholangiography and the Treatment of Choledocolithiasis: Our Experience in Transitioning from the Traditional Four Port Cholecystectomy to SILS and Beyond.

Ibrahim Daoud, MD, Randall Kimball, MD, Brendan O’Connell, MD, Brian Pellini, MD, Stanton Smith, MD

St. Francis Hospital, Hartford, CT

Introduction: Since the advent of laparoscopic cholecystectomy, there have been arguments for and against routine cholangiography. Many of these arguments focus on the identification of anatomical abnormalities and the recognition of biliary injuries. Another area of interest is the identification of choledocolithiais and the ability to address these findings at the time of cholecystectomy. We present our experience with routine cholangiography and laparoscopic common bile duct (CBD) exploration in traditional four port, SILS, robotic four port and robotic SILS (rSILS) procedures.

Methods: We retrospectively reviewed the charts of urgent and elective laparoscopic cholecystectomies performed by a single surgeon over a 5 year period. All procedures were performed with routine cholangiography.

Results: 546 cases of laparoscopic cholecystectomies were identified (384 traditional four port, 138 SILS, 11 robotic four port, 13 rSILS), and 6% (35) had associated common bile duct stones. 5 had symptoms of biliary obstruction and underwent preoperative ERCP, and 29 patients (5%) were found to have choledocolithiasis at the time of cholecystectomy. 6 patients presented as acute cholecystitis. 69% (20) were successfully treated with laparoscopic CBD exploration (including 1 SILS) and 9 (31%) required postoperative ERCP (2 assisted by the rendezvous technique).

Conclusions: This series shows that routine cholangiography will identify choledocolithiasis in 6% of cases. In those patients who do not show evidence of choledocolithiasis preoperatively, cholangiography allows the surgeon to identify and treat these stones either at the time of operation, or in the immediate postoperative period. Routine cholangiography and laparoscopic CBD exploration is also technically feasible in SILS, four port robotic and rSILS procedures. By maintaining proficiency in cholangiography and CBD exploration during traditional four port cholecystectomy, the surgeon will be able to better address choledocolithiasis when found during more advanced laparoscopic approaches such as SILS and robotic procedures.

Session: Poster Presentation

Program Number: P344

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